Provider Demographics
NPI:1902000904
Name:FAMILY VISION CARE OF PONCA CITY
Entity Type:Organization
Organization Name:FAMILY VISION CARE OF PONCA CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-762-5700
Mailing Address - Street 1:1619 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2703
Mailing Address - Country:US
Mailing Address - Phone:580-762-5700
Mailing Address - Fax:580-765-3022
Practice Address - Street 1:1619 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2703
Practice Address - Country:US
Practice Address - Phone:580-762-5700
Practice Address - Fax:580-765-3022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK2144152W00000X, 332B00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100634170BMedicaid
OKOKB5841Medicare PIN
OK1020390001Medicare NSC